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Referrals 
Thank you for your interest in Evolution Counseling Associates. There are 4 sections to this form. If you are completing for just you, you can stop at section 1. If you are completing for couples counseling, please complete section 1 and 2, if you are completing for a minor, please complete section 1 and 3, if you are completing for a family, please complete section 1 and 4. 
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I am seeking services for (check all that apply): *
Required
Are you currently OR have you been a client of Evolution Counseling Associates? *
I am submitting this form for:  *
Section 1 (Individual)
Complete this section. If you are submitting for just yourself, please select next at the bottom of the next 3 sections and click SUBMIT. 
Name (person completing form):  *
DOB *
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Preferred email: *
Preferred phone #: *
Preferred location (select all possible options):  *
Required
Preferred days:  *
Required
Preferred times (please specify if you are flexible with time):  *
Primary focus for counseling (i.e. anxiety, depression, stress, life transitions):  *
Insurance Provider (*we are not credentialed with Medicaid or Medicare, Blue Home with Atrium, Blue Home with UNC Health Alliance, Blue Local, and Blue Home with Cone Health. Unfortunately we can not accept this insurance as payment towards claims.  *
State of Residence:  *
Copay (if known): 
Deductible (if known): 
If you are interested in a specific therapist, please provide their name here: 
If you have discussed a date and time with a therapist directly, please provide it here: 
Additional information: 
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